Moore, Michael B DH-PHS-BTP-85zr-, VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
Mae Pebrua 1991
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Q ° 0 Ft. Sill,, Oklahoma
7. Name and Address of Funeral Director or Authorized Person
Douglas V. King, Durlee Funeral Home, Fair Haven Vermont 05743
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from A Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION A� (If temporary storage. complete this section.)
Place of Storage(Name of Cemetery or Vault) CitylTown, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION 13� (If removal from temporary storage or disinterment, complete this section.)
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official 7—Date
SECTION . • body will •-
Name of Crematorium City/Town, State -T Date
Pine View Crematox!y Queensbury, New Tork 8 91
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signatu of Clerk or Dej2V City/Town Date
Rutland 8 1
Sig re of Cr atorium Officid Container Number Date
�o _$-9/
SECTIO omplete this section ••• be buried or • •e•
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑ Entombed Date
Name of Cemetery Section Lot Number Grave Number
CitylT'own, State Signature of Sexton/Cemetery Official
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18,V.S.A. 5215)